Provider Demographics
NPI:1265614234
Name:RYAN, MARILYN G (RPH)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:G
Last Name:RYAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3649 ERIE BLVD E
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:NY
Mailing Address - Zip Code:13214-2738
Mailing Address - Country:US
Mailing Address - Phone:315-445-1356
Mailing Address - Fax:315-445-3008
Practice Address - Street 1:3649 ERIE BLVD E
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:NY
Practice Address - Zip Code:13214-2738
Practice Address - Country:US
Practice Address - Phone:315-445-1356
Practice Address - Fax:315-445-3008
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036509-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00482742Medicaid